Thomas P. Sokol, MD received his medical degree from the University of Health Sciences/The Chicago Medical School in 1980. He went on to his general surgical residency at Harbor/UCLA Medical Center and then to the Carle Clinic/ University of Illinois for Fellowship Training in Colon and Rectal Surgery.
Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
The vast majority of patients with
symptom-causing hemorrhoids are able to be managed with non-surgical techniques.
In the practice of a surgeon adept at managing hemorrhoids non-operatively, it
is estimated that less than 10% of patients require surgery if the hemorrhoids are treated early.
Dilation: Forceful dilation of the anal sphincter by stretching the anal canal
has been used to weaken the anal sphincter, the assumption being that the
increased sphincter pressure is responsible for the hemorrhoids. Unfortunately,
the dilation frequently damages the sphincter itself and many patients become
incontinent or unable to control their stool after dilation. For this reason,
dilation is rarely used to treat hemorrhoids.
Doppler ligation: Recently,
the use of a special, illuminated anoscope with a Doppler probe that measures blood flow has enabled doctors to identify the
individual artery that fills the hemorrhoidal vessels. The doctor then can tie
off (ligate) the artery. This causes the hemorrhoid to shrink. The Doppler probe
is expensive, and seems may offer little advantage over rubber band ligation.
Sphincterotomy: Occasionally, the internal portion of the anal sphincter is
partially cut in an attempt to reduce the pressure of the sphincter within the
anal canal. This procedure is rarely used alone, and there is concern about
incontinence (loss of control) of stool as a potential complication.
Hemorrhoidectomy: Non-operative treatment is preferred because it is associated
with less pain and fewer complications than operative treatment. Surgical
removal of hemorrhoids (hemorrhoidectomy) usually is reserved for patients with
third- or fourth-degree hemorrhoids.
During hemorrhoidectomy, the internal hemorrhoids and external hemorrhoids are cut
out. The wounds left by the removal may be sutured (stitched) together (closed
technique) or left open (open technique). The results with both techniques
are similar. At times, a proctoplasty also is done. A proctoplasty extends
the removal of tissue higher into the anal canal so that redundant or prolapsing
anal lining also is removed.
Postsurgical pain is a major problem with
hemorrhoidectomy. Potent pain medications (narcotics) usually are required. The
addition of nonsteroidal antiinflammatory drugs (NSAIDs) such as
ketorolac
(Toradol), celecoxib (Celebrex),
valdecoxib (Bextra) enhances
the relief of pain, yet patients still do not return to work for 2-4 weeks.
Several other complications may occur following hemorrhoidectomy. Urinary
retention (difficulty urinating) occurs in about 5% of patients. Although
retention almost always is transient, it may require catheterization (insertion
of a tube) to empty the bladder. Delayed bleeding or hemorrhage 7 to 14 days after surgery
occurs in 1%-2% of patients. Narrowing of the anus due to scarring, formation of
fissures, and infection (1% of patients) also may occur. Incontinence of stool
(inability to control the passage of stool) is uncommon unless the anal
sphincter is damaged. Finally, blood clots may form in external hemorrhoids
following surgery if they are not removed.
Stapled hemorrhoidectomy: This is the newest surgical technique for treating
hemorrhoids, and it has rapidly become the treatment of choice for third-degree
hemorrhoids. Stapled hemorrhoidectomy is a misnomer since the surgery does not
remove the hemorrhoids but, rather, the abnormally lax and expanded hemorrhoidal
supporting tissue that has allowed the hemorrhoids to prolapse downward.
For stapled hemorrhoidectomy, a circular, hollow tube is inserted into the anal
canal. Through this tube, a suture (a long thread) is placed,
actually woven, circumferentially within the anal canal above the internal
hemorrhoids. The ends of the suture are brought out of the anus through the
hollow tube. The stapler (a disposable instrument with a circular stapling
device at the end) is placed through the first hollow tube and the ends of the
suture are pulled. Pulling the suture pulls the expanded hemorrhoidal supporting
tissue into the jaws of the stapler. The hemorrhoidal cushions are pulled back
up into their normal position within the anal canal. The stapler then is fired.
When it fires, the stapler cuts off the circumferential ring of expanded hemorrhoidal tissue trapped within
the stapler and at the same time staples together the upper and lower edges of
the cut tissue.
Stapled hemorrhoidectomy, although it can be used to treat second degree hemorrhoids, usually is reserved for higher grades of hemorrhoids - third and fourth degree. If in addition to internal hemorrhoids there are small external hemorrhoids that are causing a problem, the external hemorrhoids may become less problematic after the stapled hemorrhoidectomy. Another alternative is to do a stapled hemorrhoidectomy and a simple excision of the external hemorrhoids. If the external hemorrhoids are large, a standard surgical hemorrhoidectomy may need to be done to remove both the internal and external hemorrhoids.
Picture Internal Hemorrhoids in Anal Canal
Picture of a Hollow Tube Inserted into the Anal Canal and Pushing up the Hemorrhoids
Picture of Suturing the Anal Canal through the Hollow Tube
Picture of Bringing Expanded Hemorrhoidal Supporting Tissue into the Hollow Tube by Pulling on Suture
Picture of Hemorrhoids Pulled Back Above Anal Canal after Stapling and Removal of Hemorrhoidal Supporting Tissue
During stapled hemorrhoidectomy, the arterial blood vessels that travel within
the expanded hemorrhoidal tissue and feed the hemorrhoidal vessels are cut,
thereby reducing the blood flow to the hemorrhoidal vessels and reducing the
size of the hemorrhoids. During the healing of the cut tissues around the
staples, scar tissue forms, and this scar tissue anchors the hemorrhoidal
cushions in their normal position higher in the anal canal. The staples are
needed only until the tissue heals. They then fall off and pass in the stool
unnoticed after several weeks. Stapled hemorrhoidectomy is designed primarily to
treat internal hemorrhoids, but if external hemorrhoids are present, they may be
reduced as well.
Stapled hemorrhoidectomy is faster than traditional hemorrhoidectomy, taking
approximately 30 minutes. It is associated with much less pain than traditional
hemorrhoidectomy and patients usually return earlier to work. Patients often
sense a fullness or pressure within the rectum as if they need to defecate, but
this usually resolves within several days. The risks of stapled hemorrhoidectomy
include bleeding, infection, anal fissuring (tearing of the lining of the anal
canal), narrowing of the anal or rectal wall due to scarring, persistence of
internal or external hemorrhoids, and, rarely, trauma to the rectal wall.
Stapled hemorrhoidectomy may be used to treat patients who have both internal and external hemorrhoids; however, it also is an option to combine a stapled hemorrhoidectomy to treat the internal hemorrhoids and a simple resection of the external hemorrhoids.
Rectal bleeding (hematochezia) refers to the passage of bright red blood from the anus. Rectal bleeding may be moderate to severe and most bleeding comes from the colon, rectum, or anus. Common causes include anal fissures, hemorrhoids, diverticulitis, and more.
Diarrhea is a change is the frequency and looseness of bowel movements. Cramping, abdominal pain, and the sensation of rectal urgency are all symptoms of diarrhea. Absorbents and anti-motility medications are used to treat diarrhea.
There are many symptoms involved in the 1st, 2nd and 3rd trimesters of pregnancy. The first early pregnancy symptom is typically a missed period, but others include breast swelling and tenderness, nausea and sometimes vomiting, fatigue and bloating. Second trimester symptoms include backache, weight gain, itching, and possible stretch marks. Third trimester symptoms are additional weight gain, heartburn, hemorrhoids, swelling of the ankles, fingers, and face, breast tenderness, and trouble sleeping. Read more to learn about recommended procedures and tests for each stage of a healthy pregnancy.
Constipation is defined medically as fewer than three stools per week and severe constipation as less than one stool per week. Constipation usually is caused by the slow movement of stool through the colon. There are many causes of constipation including medications, poor bowel habits, low fiber diets, abuse of laxatives, hormonal disorders, and diseases primarily of other parts of the body that also affect the colon.
A skin tag is a small benign growth of skin that projects from the surrounding skin. Skin tags can vary in appearance (smooth, irregular, flesh colored, dark pigment, raised). Skin tags generally do not cause symptoms unless repeatedly irritated. Treatment for skin tag varies depending on the location on the body.
Anal itching is the irritation of the skin at the exit of the rectum, known as the anus, accompanied by the desire to scratch. Causes include everything from irritating foods we eat, to certain disease and infections. Treatment options include local anesthetics, vasoconstrictors, protectants, astringents, antiseptics, keratolytics, analgesics, and corticosteroids. If condition persists, a doctor examination may be needed to identify an underlying cause.
An anal fissure is a small tear or cut in the skin lining of the anus. Pain and/or rectal bleeding during bowel movements are common symptoms of anal fissures. Treatment involves increasing liquid intake, using stool softeners and avoiding foods that may not be well-digested.
Laxatives for treatment of constipation include over-the-counter preparations such as bulk-forming laxatives, stool softeners, lubricant laxatives, stimulant laxatives, saline laxatives, enemas and suppositories. Some over-the-counter laxatives are not recommended for patients with specific diseases or conditions. Some laxatives may have negative adverse effects if taken over long periods of time.
Portal hypertension is most commonly caused by cirrhosis, a disease in which results from scarring of a liver injury. Other causes of portal hypertension include blood clots in the portal vein, blockages of the veins that carry the blood from teh liver to the heart, and a parasitic infection called schistosomiasis.
Pregnancy can bring challenges like weight gain, stretch marks, varicose veins, heartburn, constipation, hemorrhoids, problems sleeping, and wondering if it is safe to have sex while pregnant. Learn how to manage and move through these challenges during pregnancy.
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